The adolescent with a broken leg from a skiing accident,

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1 RESEARCH NURSES KNOWLEDGE AND ATTITUDES TOWARD PAIN IN THE EMERGENCY DEPARTMENT Authors: Joane T. Moceri, PhD, RN, and Denise J. Drevdahl, PhD, RN, Tacoma, WA Earn Up to 9.0 CE Hours. See page 108. Introduction: The purpose of this study was to investigate emergency nurses knowledge and attitudes about pain. Methods: A descriptive design was used for this study. A validated tool, the Knowledge and Attitudes Survey Regarding Pain (KASRP), was administered to nurses working in 5 U.S. emergency departments. Demographic data also were collected from each participant. Results: Ninety-one emergency nurses completed the survey. The mean total KASRP score was 76%. No significant differences were found in mean total scores by age, education level, years of nursing experience, or years of ED experience. Eight questions were answered incorrectly by more than 50% of participants. Five of these questions were related to opioid pharmacology and dosage, 2 concerned understanding of addiction and dependence, and one was linked to nurse assessment and patient report of pain level. Analysis of these 8 questions revealed that higher education levels had a weak positive association with correct answers. Discussion: Participants taking the survey scored comparably or better than participants in other reported studies using the KASRP. Years of nursing experience was not correlated with correct responses. Findings from this study underscore the Institute of Medicine s Pain in America recommendation to increase pain management education for all providers. Key words: Pain; Pain management; Analgesics; Opioid; Nurse; Emergency department The adolescent with a broken leg from a skiing accident, the factory worker with a lacerated hand, the woman in sickle cell crisis all are instances that bring the patient to the emergency department for treatment of his or her pain. Pain is one of the most common symptoms seen in the emergency department, 1 with chest pain and abdominal pain being the most prevalent types of pain reported. 2 The 2011 Pain in America report by the Institute of Medicine 3 was emphatic in its declaration that pain, especially chronic pain, is an undertreated condition in the United States across health care settings and providers. Although the medical literature is abundant with Joane T. Moceri is Assistant Professor, University of Washington Tacoma, Tacoma, WA. Denise J. Drevdahl is Associate Professor, University of Washington Tacoma, Tacoma, WA. Supported by the Chancellors Fund for Research Scholarship Support, University of Washington Tacoma, Tacoma, WA. For correspondence, write: Joane Moceri, PhD, RN, 1125 NW 12th Avenue, #508, Portland, OR 97209; joanemoceri@gmail.com. J Emerg Nurs 2014;40:6-12. Available online 26 July /$36.00 Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. respect to patients experiences of pain and their preferences for and dissatisfaction with pain management, less is known about how providers, particularly registered nurses (RNs), make pain management decisions. Because a nurse s knowledge and attitude toward pain inform how she or he manages a patient s pain, this article reports findings from a study that explored emergency nurses understanding of pain and the medications used to treat pain. Differences in how providers perceive, assess, and treat pain exist in all clinical settings. 3,4 Research suggests that physicians analgesic and opioid prescribing decisions are influenced by a variety of factors, resulting in care disparities. Some studies found that pain treatment decisions primarily were influenced by the physician s gender,along with the physician s training and experience. 5,6 Organizational features of the health care system also may contribute to pain management decision making; as a result, time spent in the emergency department, the type of triage system used, and ED crowding may lengthen the time that elapses before pain assessment, medication prescription, and administration of pain medication. 7,8 Finally, patients personal characteristics have an effect on providers clinical decision making, with numerous studies documenting disparities in pain management based on the patient s race, age, gender, and/or socioeconomic status Although some studies have examined emergency nurses decision making with respect to ED triage assessment, 12,13 6 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 1 January 2014

2 Moceri and Drevdahl/RESEARCH TABLE 1 The 8 most difficult questions (correct answer and mean score in parentheses) from Ferrell and McCaffery's Knowledge and Attitudes Survey Regarding Pain (KASRP) 6. T/F: Respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months. (T; 39.6%) 9. T/F: Research shows that promethazine (Phenergan) and hydroxyzine (Vistaril) are reliable potentiators of opioid analgesics. (F; 48.3%) 18. T/F: Vicodin (hydrocodone 5 mg + acetaminophen 500 mg) PO is approximately equal to 5 10 mg of morphine PO. (T; 34.4%) 26. Which of the following IV doses of morphine administered over a 4-hour period would be equivalent to 30 mg of oral morphine given q 4 hours? (b. Morphine 10 mg IV; 48.9%) 28. A patient with persistent cancer pain has been receiving daily opioid analgesics for 2 months. Yesterday the patient was receiving morphine 200 mg/hour intravenously. Today he has been receiving 250 mg/hour intravenously. The likelihood of the patient developing clinically significant respiratory depression in the absence of new comorbidity is (a. less than 1%; 21.8%) 33. How likely is it that patients who develop pain already have an alcohol and/or drug abuse problem? (5%-15%; 24.4%) 36. Following abrupt discontinuation of an opioid, physical dependence is manifested by the following: (a. sweating, yawning, diarrhea and agitation with patients when the opioid is abruptly discontinued; 34.4%) 37. B. Andrew is 25 years old and this is his first day following abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals the following information: BP = 120/80; HR = 80; R = 18; on a scale of 0 to 10 (0 = no pain/discomfort, 10 = worst pain/discomfort) he rates his pain as 8. Your assessment, above, is made 2 hours after he received morphine 2 mg IV. Half hourly pain ratings following the injection ranged from 6 to 8 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. He has identified 2/10 as an acceptable level of pain relief. His physician's order for analgesia is morphine IV 1 3 mg q1h PRN pain relief. Check the action you will take at this time. (4. Administer morphine 3 mg IV now; 48.2%.) BP, Blood pressure; HR, heart rate; IV, intravenous; PO, by mouth; q, every; R, respirations. little is known about emergency nurses understanding and attitudes regarding pain, because the vast majority of studies have evaluated ED physician pain medication prescribing practices. Yet it is emergency nurses who assess patient pain and administer pain medication. Emergency nurses have identified several barriers to treating patients pain, including inadequate pain management knowledge, inability to medicate until a diagnosis is made, lack of time to assess and control pain, and patients use of alcohol or other drugs. 14,15 Other investigators also found that emergency nurses often underestimated patients pain intensity. 16 Because a review of the extant literature revealed no studies that examined U.S. emergency nurses understanding of pain, the specific objective of the study was to measure emergency nurses knowledge and attitudes about pain. This line of inquiry is important because a wide cross section of U.S. society frequently uses the emergency department as a primary source of care. 17 Findings from this study add important information to the literature regarding what nurses know about patients pain in the emergency department and can be used to inform future interventions that improve pain assessment and treatment. Therefore this area of study has the potential to change practice and thus improve patient care and health outcomes for a broad spectrum of society. Methods DATA COLLECTION Data about emergency nurses knowledge and attitudes toward pain were gathered using Ferrell and McCaffery s Knowledge and Attitudes Survey Regarding Pain (KASRP). 18 The KASRP is a validated survey instrument (Cronbach s α >.70) that has been used in several studies and consists of 22 true and false questions, 13 multiple choice questions, and 2 case vignettes with 2 questions each (sample questions are provided in Table 1). Emergency nurses completed the survey either electronically or in paper format and were given the ability to remain anonymous if they chose. Demographic data were collected about each participant s race/ethnicity, age, gender, highest level of education, years as a nurse, and years as an emergency nurse. SETTING AND SAMPLE This study was conducted in 5 hospital emergency departments located in the Pacific Northwest region of the United States. Institutional review and approval was obtained from the University of Washington Humans Subjects Division, as well as from the institutional review boards of each participating hospital. Approximately 365 nurses who worked in the emergency departments of these 5 hospitals, January 2014 VOLUME 40 ISSUE 1 7

3 RESEARCH/Moceri and Drevdahl excluding administrators, were eligible and invited to participate in the study through letters and flyers posted in emergency departments. Additionally, ED nurse managers at each site informed staff nurses about the study and encouraged them to participate. DATA ANALYSIS Data from the KASRP were analyzed using PASW version 18.0 software. Following the recommendation of Ferrell and McCaffery, 18 the data were analyzed using the percentages of total scores rather than attempting to separate the questions into categories of knowledge or attitudes, because some items measure both domains. Mean total survey scores were calculated for each participant, survey questions were analyzed for frequency of correct and incorrect answers, and as suggested by Ferrell and McCaffrey, 18 items with the least number of correct answers were explored further. Descriptive statistics, including frequencies and means, as well as analysis of variance (ANOVA), were used to compare differences in scores by demographic characteristics of age, education level, years of nursing experience, and years of ED nursing experience. Results Ninety-one RNs completed and returned the survey for a response rate of 25%. The majority of respondents were white (75.6%), with the next largest ethnic group being Latino/Hispanic (4.4%). The racial/ethnic representation was typical for white nurses in the United States but was higher than the national average for Latino nurses. 23 The representation of Asian and African American nurses was less than would be expected from national distributions. 23 The largest age group was between 20 and 30 years, which was nearly double that of the next largest age group (31-49 years). This sample of emergency nurses comprised a large group of younger nurses, as well as nurses with 2 or fewer years of emergency nursing experience. These characteristics may be attributed to the fact that 85% of RNs younger than age 30 years work in hospital settings, whereas fewer than 50% of RNs older age 55 years work in hospital settings. 23 The mean number of years of nursing experience was 8.4, with 31.1% having 2 years or less experience in nursing. The mean number of years of ED experience was 5.9 years, with 38.9% having 2 years or less ED experience. More than half (51.1%) had associate degrees in nursing (ADN), 37.8% had a baccalaureate nursing degree (BSN), and 11% held a graduate degree in nursing (MN/MS). The distribution of education levels in the sample was similar to that described by the National Sample Survey of Registered Nurses 23 for those employed in emergency departments, with the exception of those with Masters degrees, who were slightly higher in number than would be expected from national statistics (11.1% compared with 7.3% nationally). Table 2 summarizes the demographic information. In this study, the mean total score for the KASRP was 76%. Scores ranged from 32.5% to 92.5%, with a standard deviation of A score of 80% or higher, representing adequate knowledge about pain management, 18 was achieved by 41% of participants, with 4.4% of all participants receiving a score of 90% or higher. ANOVA was conducted to detect differences in mean total scores by age, years of nursing experience, years of ED experience, and/or level of education. Results showed no significant differences in mean total scores by age or years of nursing experience, including ED experience. Further, no significant difference in mean total scores was detected among nurses with ADN, BSN, or MN/MS education levels. Questions answered correctly by 90% or more participants tended to be more general questions about pain and pain assessment rather than specific questions about medications, dosage, or treatments for pain. Based on procedures used in earlier studies, we examined the 8 questions that were answered incorrectly by more than 50% of participants, because these questions represent limited pain management knowledge. Five questions were related to opioid pharmacology and dosage, 2 concerned understanding of addiction and dependence, and one was related to nurse assessment and patient report of pain level. Table 1 shows these 8 questions and the mean total scores for each. ANOVA of the questions about opioid pharmacology and dosage demonstrated significant between group differences for education level (df =3,F = 4.528, P =.005), with higher education levels weakly positively associated with correct answers (r =.155). However, no differences were detected between groups for years of nursing experience or years of emergency nursing experience. In a question about drug addiction/dependency, significant differences by education level, years of nursing experience, and years of ED nursing experience were detected (df = 3, F = 8.836, P =.005). Respondents with higher education levels, more years of nursing experience, and greater time in the emergency department selected the correct response more frequently. This question proved to be the only one where significant differences were demonstrated between groups in each of these categories. For the case vignette question related to opioid dosage and pain scale, only 44% of participants provided the correct answer, indicating that these emergency nurses tended to believe their own assessment over the patients self-reports of pain and thus leaned toward undertreatment. 8 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 1 January 2014

4 Moceri and Drevdahl/RESEARCH TABLE 2 Demographic characteristics (n = 91) Characteristic Participants (%) National average (%) N % Race/ethnicity White Latino African American Asian Age (y) Education level ADN BSN MN/MS Missing 3 Years experience Years ED experience ADN, Associate degree in nursing; BSN, Bachelor of Science in Nursing degree; MN/MS, Master's degree in nursing/master of Science. Discussion With a mean total score of 76%, the participants in the survey performed comparably or better than nurses in other studies using the KASRP; a limited number of these studies have been carried out in the United States, with the majority conducted internationally. The few studies conducted in the United States revealed that perianesthesia nurses earned a mean score of 72%, 19 whereas nurses with oncology certification achieved a mean score of 77.5% compared with 72.5% for those without certification. 20 The average score from a study of Turkish nurses was 35%, 21 and it was 55% for a study conducted in Italy, 24 whereas studies from Ireland and Great Britain demonstrated scores in the mid 70s. 22,25 These studies did not describe scores in terms of education levels or years of experience. Although a limited number of emergency nurses who participated in the current study had more than 10 years of nursing experience (n = 23), similar research demonstrates mixed results for years of experience as an important factor in pain knowledge. For example, participants in China received an average score of 47%, which was significantly positively correlated with years of experience, 27 and Tsai et al. 28 reported a mean score of 49% for Taiwanese nurses, which also was significantly positively correlated with years of experience. Yet a survey by Wilson 29 of nurses knowledge of pain revealed that their knowledge scores were not associated with their years of nursing experience, and Lewthwaite et al. 30 reported that 49% of Canadian nurses received a total score of 80% or higher, with negative correlations among age, experience, and score, but a positive correlation between score and education level. Finally, in a large multi-state study examining the links among staffing, nursing education, and patient mortality, Aiken et al. 31 found that nurses years of experience was not a critical factor in pre- January 2014 VOLUME 40 ISSUE 1 9

5 RESEARCH/Moceri and Drevdahl dicting patient mortality, but education at the BSN level or higher did make a positive difference in mortality for surgical patients. The finding in this study of no significant differences between education levels and mean total scores is interesting in light of the work by Aiken and colleagues 31 and may indicate that continuing education related to pain management is more important than years of experience or educationlevel.thisfindingalsomaysuggestthatitisnot education level that affects general knowledge and attitudes about pain but rather that education level may affect specialized knowledge related to opioid use. Thus additional offerings about pain and pain management at all education levels and regardless of years of experience in nursing in general, or even specifically in the emergency department, seem warranted. According to the literature, persons who take a pain management course score higher on the KASRP than those who do not take such a course. For example, the study by LeMay et al. 32 demonstrated a 7% improvement in scores for pediatric nurses who completed pain management workshops. Likewise, Bernardi et al. 24 reported a mean score of 51% for nurses who had not previously taken a pain management course, with scores of 59% associated with more education about pain management. Thus nurses in the present sample who complete a pain management course could expect their KASRP scores to increase by 7% to 8%, reaching an adequate score of greater than 80%. The studies by LeMay et al. 32 and Bernardi et al. 24 provide evidence that supports calls by the Institute of Medicine 3 to increase pain management education at all provider levels and for some providers to become experts in pain management. Importantly, although several curricula are available, little in the area of pain management education has been implemented. 24 Although no differences were detected in mean scores among age levels, years of experience, or education levels, the findings demonstrate that nurses in the study were most unfamiliar with topics related to opioids, including pharmacology and dependency or abuse. This finding concurs with the report by Tanabe and Buschmann 14 that RNs had knowledge deficits in the area of pharmacologic analgesic principles and points to the conundrum of opioids 3 in which nurses continue to be concerned with opioid use. This conundrum is demonstrated in the responses to the case vignette questions in which emergency nurses, as a consequence of favoring their own pain assessment over that of patients, undertreated patients pain. These responses imply that nurses still may be unwilling to believe the patient s reporting of pain levels, especially when the patient s behavior does not meet the nurse s expectations of how a patient with a pain number of 8, for example, should behave. However, even when the study participants agreed with the patients assessment of their own pain, nurses still tended to make decisions to undertreat. This finding highlights both the complexity of pain assessment and the need for a better understanding of pain and the attitudes surrounding pain that may maintain the status quo of wide disparities in pain management. Further, these results are congruent with similar research, which found that nurses believed that patients exaggerate their pain and/or that nurses underestimated patients pain, both of which maycontributetoinadequatepaintreatment. 33,34 It is critical that nurses have a deep understanding of opioids, given the widespread use of these forms of drugs across the United States. 3 LIMITATIONS This study has several limitations. Because a convenience sample was used, only the RNs interested in the study took part, and they may not be representative of all ED RNs. Although the racial/ethnic make-up of the sample mirrored the racial/ethnic demographics of the Pacific Northwest, it was not representative of RNs across the United States, particularly for African Americans/blacks and Asians, who were largely underrepresented. A third limitation was the small numberofparticipantswith more than 10 years of experience, although, as stated earlier, this factor may have less importance than is typically assumed. Emergency nurses with a master s degree were overrepresented compared with national statistics. Finally, a lack of significant findings concerning differences in scores by experience or education level may indicate that this study was underpowered, although the study by Coleman et al. 20 with approximately the same sample size was determined to be powerful enough to detect differences between nurses with oncology nursing certification and those without it. IMPLICATIONS FOR EMERGENCY NURSES Findings from this study support prior research that points to providers underprescribing pain medications to ED patients 16 and demonstrate the need for research and education on effective analgesic practice. 3 Although it is unknown if the emergency nurses responses to the survey are directly tied to the actual provision of their nursing care, the results reported here indicate a need for targeted education to ED nurses, especially with respect to opioid pharmacology and dosing, regardless of the nurse s years of experience or education level. Because educational inter- 10 JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 1 January 2014

6 Moceri and Drevdahl/RESEARCH ventions directed toward changing pain treatment in the emergency department have demonstrated mixed results, 35 this type of intervention should be conducted as part of a formal research process to determine the best educational delivery models. Given that the Pain in America report 3 recommends that additional data on pain be collected, one mechanism to consider is for emergency departments to conduct retrospective chart reviews of ED discharges. 36 Analyzing each discharge and the administration of pain medication in terms of patient diagnosis, age, race/ethnicity, and gender, for example, may reveal differential patterns of pain prescriptions. Once identified, steps can be taken to eliminate disparate care. In conclusion, pain remains an important issue for persons visiting the emergency department. Decreasing pain management disparities is important because the principle of justice mandates that providers, including emergency nurses, offer effective pain management to all patients. Making informed decisions about pain management requires expert knowledge of opioids and the ability to conduct a thorough pain assessment, which includes taking into account both objective data and the patients subjective experiences of pain. REFERENCES 1. Cordell WH, Keene KK, Giles BK, Jones JB, Jones JH, Brizendine EJ. The high prevalence of pain in emergency medical care. Am J Emerg Med. 2002;20: Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. Washington, DC: National Center for Health Statistics; 2010;26: Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; Green CR, Anderson KO, Baker TA, et al. 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7 RESEARCH/Moceri and Drevdahl 31. Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011; 49(12): LeMay S, Johnston CC, Choiniere M, et al. Pain management practices in a pediatric emergency room (PAMPER) study: interventions with nurses. Pediatr Emerg Care. 2009;25: McCaffery M, Grimm MA, Pasero C, Ferrell B, Uman GC. On the meaning of drug seeking. Pain Manag Nurs. 2005;6: Hazelett S, Powell C, Androulakakis V. Patients behavior at the time of injury: effect on nurses perception of pain level and subsequent treatment. Pain Manag Nurs. 2002;3: Froschnot DE, Swanson ER, Barton ED. Changing attitudes about pain and pain control in emergency medicine. Emerg Med Clin North Am. 2005;23: Richardson LD, Babcock Irvin C, Tamayo-Sarver JH. Racial and ethnic disparities in the clinical practice of emergency medicine. Acad Emerg Med. 2003;10: JOURNAL OF EMERGENCY NURSING VOLUME 40 ISSUE 1 January 2014